Rainbow Place Registration

Account Information

Username

Password

Parent/Guardian Information

Date

Mother/Guardian

Name

First Middle Last

Address

Occupation

Home Phone(Required)

Employed By

Office Phone(Required)

Work Address

Work Hours

:

Cell Phone(Required)

Custodial Parent (If married, mark both parents)

Date of Birth

Guardian Email

Driver's License #

Marital Status

Married

Single

Divorced

Separated

Widowed

Other

Father/Guardian

Name

First Middle Last

Address

Occupation

Home Phone

Employed By

Office Phone

Work Address

Work Hours

:

Cell Phone

Custodial Parent (If married, mark both parents)

Date of Birth

Email

Driver's License #

Marital Status

Married

Single

Divorced

Separated

Widowed

Other

Child Information

Full-Time/Part-Time

Days: Mon. Tues. Wed. Thurs. Fri.

Child

Name

First Middle Last

Name child prefers to be called

Location

Child’s Address

Gender

Male

Female

Date of Birth

Child's S.S. #

List any existing medical conditions, medication and/or special attention your child may require?

Allergies

Pediatrician’s Name:

Phone

Address

Photographs: May we take and maintain a photo of your child for security purposes?

Yes

No

Authorization for Emergency
I hereby Grant the staff of Rainbow Palace to seek emergency medical care for my child: ___________________. The staff will attempt to contact the child’s parents or guardians to inform them of the emergency. However, such communication is not a precondition to the permission and authorization herein the staff of Rainbow Palace.

Sign

Date

Emergency Contacts & Authorized Pickup Persons

1st Contact/Pick Up

Name

Phone

Address

Date of Birth

Relationship to the Child

Pick up the children

Able to pick up all children in the family

Not able to pick up the following children:

Not able to pick up the following children

2nd Contact/Pick Up

Name

Phone

Address

Date of Birth

Relationship to the Child

Pick up the children

Able to pick up all children in the family

Not able to pick up the following children:

Not able to pick up the following children

4th Contact/Pick Up

Name

Phone

Address

Date of Birth

Relationship to the Child

Pick up the children

Able to pick up all children in the family

Not able to pick up the following children:

3rd Contact/Pick Up

Name

Phone

Address

Date of Birth

Relationship to the Child

Pick up the children

Able to pick up all children in the family

Not able to pick up the following children:

Parent's Signature

Date